Appendicitis at children – sharp (is more rare subsharp, chronic) an inflammation in a worm-shaped shoot (appendix). Appendicitis at children proceeds with belly-aches, one - or double vomiting, the speeded-up chair, temperature reaction, decrease of the activity, concern. Diagnostics includes a stomach palpation, rectal manual inspection; research of the general blood test and urine; Ultrasonography, X-ray analysis or KT of an abdominal cavity; diagnostic laparoscopy. Detection of appendicitis demands carrying out an appendektomiya, preferably laparoscopic way.
Appendicitis at children
Acute appendicitis – the most widespread urgentny disease in children's surgery (75% of the emergency operations). At children it is necessary to face appendicitis not only to children's surgeons, but also pediatricians, children's gastroenterologists, children's gynecologists. At children's age a shoot inflammation the blind person of a gut develops promptly that causes increase of destructive changes in an appendix during rather short time. At appendicitis at the child the peritoneum is often involved in inflammatory process, leading to development of appendicular peritonitis.
The peak of incidence of appendicitis at children (over 80% of cases) is the share of school age, at preschool children the disease occurs in 13%, at children of babyhood – in 5% of cases.
Reasons and pathogenesis
Appendicitis is a consequence of obstruction of a worm-shaped shoot and the subsequent bacterial invasion. The created or got to a koprolita shoot gleam (kalovy stones), foreign matters or parasites, a giperplaziya of lymphoid follicles, inflammatory striktura, congenital anomalies (bends, perekruta) of a worm-shaped shoot can serve as the reason of obstruction of an appendix.
Mechanical obstruction and hyperproduction of slime create elevated pressure in a gleam of a worm-shaped shoot that is followed by hypostasis mucous an appendix and strengthening of tension of its walls. In turn, it causes decrease in perfusion of a shoot, venous stagnation and reproduction of bacterial flora. In 12 hours the transmuralny inflammation develops and there is an irritation of a peritoneum. At not allowed obstruction arterial blood supply of an appendix with developing of fabric ischemia and a necrosis of all thickness of an appendicular wall is broken further. Perforation of a wall of an appendix with an exit in an abdominal cavity of purulent and fecal contents can become the following stage. Full development of appendicitis takes less than 24-36 hours.
Children up to 2 years get sick with an acute appendicitis rather seldom that is explained by features of their food and the anatomy of a worm-shaped shoot favoring to its depletion. Poor development of lymphatic follicles serves one of the reasons of infrequent developing of appendicitis in a worm-shaped shoot at children of this age. By 6-8 years the follicular device completely ripens, in parallel with it also the frequency of developing of appendicitis increases.
In development of appendicitis in children the leading role is played by own intestinal microflora and a worm-shaped shoot. Quite often hematogenic and limfogenny infection as communication of development of appendicitis with a SARS, measles, otitis, follicular quinsy, sinusitis is traced takes place.
Some infectious diseases (a typhoid, , tuberculosis, ) can independently cause appendicitis. As the contributing and provocative factors the overeating, a diet with the lowered content of cellulose and the increased content of sugar, locks, helminthoses ( at children), a gastroenteritis, dysbacteriosis can act.
According to morphological classification allocate simple (catarrhal), destructive appendicitis and empiy a worm-shaped shoot. In turn destructive appendicitis can be flegmonozny or gangrenous (in both cases – with perforation or without). Appendicitis at children not always leads to perforation of a worm-shaped shoot; in certain cases cases of spontaneous recovery meet.
The appendix at children can settle down in the right or left podvzdoshny area, subhepatic, pelvic or retrotsekalny space. Researches of the last years prove that at children development of both sharp, and chronic recurrent appendicitis is possible.
Appendicitis symptoms at children
The clinical picture of an acute appendicitis is extremely various and depends on age of the child, an arrangement of a shoot, a morphological stage of an inflammation.
Pain which in a classical case is localized in epigastralny or okolopupochny area is the earliest sign of appendicitis, and then it is displaced in an appendix projection (more often the right podvzdoshny area). At a retrotsekalny arrangement of an appendix pain is defined in a waist, at a subhepatic arrangement – in the right podreberye, at pelvic - in nadlobkovy area. Children of advanced age without effort point to localization of pain. The prevailing appendicitis symptoms at the child of younger age are the concern, crying, a sleep disorder, pulling up of legs to a stomach, resistance to survey.
The pain syndrome at appendicitis is practically always combined with refusal of food. Vomiting is the Patognomonichny sign of appendicitis: one - or double at the senior children or repeated - at kids. At appendicitis at children the chair delay can be noted; at small children, as a rule, the chair becomes more frequent and liquid with slime impurity (diarrheal appendicitis) in this connection there can quickly come dehydration.
Body temperature increases to subfebrilny or febrilny values (38-40 °C). The symptom of "scissors" which is shown discrepancy of temperature and pulse is typical for children of the senior age group. Increase of an urination (pollakiuriya) is usually observed at pelvic localization of an appendix.
At catarrhal appendicitis language at the child damp, with a raid in the field of a root; at flegmonozny appendicitis – language also remains damp, but all its surface is laid over by a white raid; at gangrenous appendicitis - language dry is also completely covered with a white raid.
Chronic appendicitis occurs at children less than at adults. It is followed by recidivous attacks of pains in the right podvzdoshny area with nausea and temperature increase.
Recognition of appendicitis demands carrying out fizikalny, laboratory, and if necessary – tool inspection of the child.
The stomach palpation at the child is followed by tension of muscles and sharp morbidity of podvzdoshny area, positive symptoms of irritation of a peritoneum (Shchetkina – Blyumberg, Voskresensky). At small children inspection is carried out during physiological or medication sleep. At difficulties of diagnostics the rectal manual research at which the overhang and morbidity of a forward wall of a rectum, infiltrate availability comes to light is conducted, other pathology is excluded.
In the general blood test also the shift of a leykotsitarny formula is defined 11-15Õ109/l to the left. The research of the general analysis of urine can reveal a jet leykotsituriya, a gematuriya, an albuminuriya. At girls of childbearing age the program of inspection includes the test for pregnancy and consultation of the children's obstetrician-gynecologist.
When performing ultrasonography of an abdominal cavity at children it is possible to reveal expanded (more than 6 cm in the diameter) a worm-shaped shoot, availability of free liquid in the right podvzdoshny pole; at perforation of an appendix periappendikulyarny phlegmon is found. At younger children for the purpose of identification of protective muscular tension the electromyography of a forward belly wall is applied.
At ambiguity in interpretation of clinical and fizikalny data performance of a X-ray analysis or KT of an abdominal cavity can be required by the child. At chronic appendicitis at children with the differential and diagnostic purpose the fibrogastroduodenoskopiya, eskretorny urography, ultrasonography of bodies of a small pelvis, a rektoromanoskopiya, a koprogramma, the analysis a calla on dysbacteriosis and on eggs of worms, a bacteriological research a calla can be carried out. The diagnostic laparoscopy, as a rule, passes into medical.
Differential diagnostics at suspicion of appendicitis at children carry out with sharp cholecystitis, pancreatitis, pyelonephritis, renal colic, adneksity, an ovary apopleksiya, reabrupt ovary cysts, a gastroenteritis, dysentery, a syndrome of the angry gut, askaridozy, koprostazy, mezadenity, right-hand pneumonia and pleurisy. The exception of the diseases which are followed by an abdominal syndrome (rheumatism, a hemorrhagic vaskulit, measles, scarlet fever, flu, quinsy, hepatitis), requires careful survey of integuments and a pharynx of the sick child.
Treatment of appendicitis at children
At suspicion of appendicitis immediate hospitalization and inspection of the child by experts is necessary. It is impossible to put to a stomach a hot-water bottle at all, to give an enema cleaning, to give the anesthetizing medicines and laxative.
Presence of acute and chronic appendicitis at children of any age serves as the absolute indication to expeditious treatment. Preference is given in pediatrics to the low-traumatic laparoscopic appendektomiya allowing to reduce terms of postoperative restoration.
At destructive forms of appendicitis preoperative preparation should not exceed 2-4 hours; at the same time to the child antibiotics are entered, infusional therapy is carried out. At the complicated appendicitis at children the open appendektomiya is carried out.
Forecast and prevention
The forecast in case of in due time performed operation is favorable. After destructive forms of appendicitis the adhesive disease can develop. The lethality at appendicitis at children makes 0,1 — 0,3%.
Great preventive value has the correct diet, observation of regular depletion of intestines of the child, treatment of chronic inflammatory diseases. It is necessary to remember that the course of appendicitis always prompt and quite often atypical therefore at any indisposition (abdominal pains, dispepsichesky frustration, temperature increase) consultation of the pediatrician is necessary.